Acorn Lodge - Surbiton

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. This is the first assessment for this newly registered service. This key question has been rated good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. The service’s culture and values were based around effective team working practices. People's choices had driven the way the care was delivered.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. A family member told us, “Well, we know [the registered manager] very well. He knows the home very well. He knows the service very well.” Staff members’ comments included, “[The registered manager] listens, I always suggest about the services users. He is a very supportive man” and “The manager tells us in a polite way. We tell him our problems and he helps.”

The provider fostered a positive culture where staff felt they could speak up and their voice would be heard. Staff were aware of the safeguarding procedure and the actions they had to take if their concerns were not appropriately addressed by the provider, commenting, “First I have to let the manager know and if the manager didn’t take any action, I have to let know the head office and then the CQC and local authority” and “I don’t have any concerns here. So far so good. We have to report our concerns and it's either the manager or someone above if the actions are not taken.”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for staff who worked for them. Policies and procedures in place supported leaders in managing staffs’ needs to ensure equity of opportunity in the workplace.

The provider had clear responsibilities, roles, systems of accountability and good governance. Regular audits were carried out in relation to people’s care records, medicines and environment. Leaders used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. The service submitted CQC notifications about the events that affect the care provision, in good time, and as necessary.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. A healthcare professional told us, “[The registered manager] has a good understanding of patients’ needs and rights of privacy. He communicates effectively with my patient and his family, and he builds a positive relationship with them. He manages to mediate effectively in conflict and can provide emotional support to patients. He updates me regularly by email, so I keep up to date of presentation, behaviours and risks.”

The provider focused on continuous learning, innovation and improvement across the organisation and local system. The service responded promptly to the feedback we provided on the day of our visit and made improvements accordingly. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. Staff were empowered to take additional responsibilities in their role, including leading on team meetings, making sure they developed and contributed to safe and effective practice.